Coding a concussion

TLGray

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I code neurology and the physician saw a new patient that had a TBI from a MVA four months ago. The CC was a headache and one of his dx was a concussion and he stated it was a new problem. The doctor thinks it should be S06.0X0A or should it be S06.0X0D. He is not treating the concussion he is treating the headache. Any help would be greatly appreciated. Thank you
 

SharonCollachi

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  • S06.0X0A Concussion without loss of consciousness, initial encounter
  • S06.0X0D Concussion without loss of consciousness, subsequent encounter
  • S06.0X0S Concussion without loss of consciousness, sequela

In 7th digit cases, "initial" and "subsequent" do not have the same meaning as they do in other uses - they do NOT mean "first" and "followup".

Tip sheet for coding initial vs. subsequent (click me)

Initial:
• 7th character “A”, initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.
• For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem.
• Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) while the patient is receiving active treatment for the fracture.
• The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

Subsequent:
• 7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, an x-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition
• Fractures are coded using the appropriate 7th character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase
• Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).

Sequela is a late effect of an injury or condition.

Now, having said all that... headache is the primary symptom of a concussion. How is he treating a headache and not a concussion? Who diagnosed the patient with a concussion? When did the patient get it? How new is "new" for this new problem?
 

TLGray

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  • S06.0X0A Concussion without loss of consciousness, initial encounter
  • S06.0X0D Concussion without loss of consciousness, subsequent encounter
  • S06.0X0S Concussion without loss of consciousness, sequela

In 7th digit cases, "initial" and "subsequent" do not have the same meaning as they do in other uses - they do NOT mean "first" and "followup".

Tip sheet for coding initial vs. subsequent (click me)

Initial:
• 7th character “A”, initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician.
• For complication codes, active treatment refers to treatment for the condition described by the code, even though it may be related to an earlier precipitating problem.
• Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) while the patient is receiving active treatment for the fracture.
• The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion.

Subsequent:
• 7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, an x-ray to check healing status of fracture, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition
• Fractures are coded using the appropriate 7th character for subsequent care for encounters after the patient has completed active treatment of the fracture and is receiving routine care for the fracture during the healing or recovery phase
• Care of complications of fractures, such as malunion and nonunion, should be reported with the appropriate 7th character for subsequent care with nonunion (K, M, N,) or subsequent care with malunion (P, Q, R).

Sequela is a late effect of an injury or condition.

Now, having said all that... headache is the primary symptom of a concussion. How is he treating a headache and not a concussion? Who diagnosed the patient with a concussion? When did the patient get it? How new is "new" for this new problem?
Thank you. Pt was diagnosed in the Emergency Room 4 months earlier but since the accident the patient is having recurrent headaches. I am so confussed on this, I coded the concussion as an intial but I have been informed that it should have been coded as a sequela instead.
 
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SharonCollachi

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I agree, if the concussion was four months ago, it's not an "A" (which I think of as "active"). I am not positive on whether it would be a D or an S.
 
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